Pictorial Case Study: third-degree uterine prolapse

A 60-year-old woman attended the surgery for a routine cervical smear.

She was seen by our practice nurse who, on asking the woman to lie down on the couch, became concerned and asked me to see her. On examination, there was a large lump lying outside the vagina partially on the couch.

Our nurse was worried that she would be unable to undertake a smear.

What is the diagnosis, management and differential diagnosis?

Diagnosis and Management
The diagnosis is third-degree uterine prolapse or procidentia, in which there is complete failure of all genital supports resulting in descent of the pelvic organs into the vagina. There is laxity and loss of tone of the muscular and fascial structures of the pelvic floor and the entire uterus lies beyond the introitus.

The woman mentioned that she had noticed some urinary symptoms including hesitancy and poor flow and that she had been aware of a lump at times.

We decided to refer her to a gynaecologist for consideration of surgery as it was felt that insertion of a pessary would be inadequate to control the prolapse, and because of her relatively young age.

Prolapse occurs predominantly in middle-aged and elderly multiparous women.

Differential diagnosis

  • Hypertrophy or elongation of the cervix, which can cause a large protrusion of tissue beyond the introitus
  • Large cystocele or rectocele.

Differential diagnosis
Rectocele

  • Results from disruption of the levator ani muscles.
  • May cause constipation and incomplete defecation.

 

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